Tag Archives: Training

Working with Separation and Divorce


diane suffridge therapistI was recently contacted by a single mom asking for therapy for her 8-year-old son.  She describes him having problems with anxiety and concentration, especially in the day or two after weekend visits with his dad.  They have had joint custody since their divorce two years ago, but mom says dad is skeptical of therapy so she wants to bring her son in for an initial appointment without talking to dad.  I usually like to meet with both parents at the beginning of child therapy, so I’m reluctant to make an exception in this case.  What should I consider in responding to mom’s request?  

Working with families involved with separation and divorce is complex, and you are wise to be thoughtful about how you approach the beginning of therapy in this case.  Chapter 7 of my book includes more detail about this topic, as well as other specialized areas of assessment.  I’ll review the legal and clinical implications of working with one or both parents in child therapy and discuss some of the factors that influence parents to request therapy for their children following divorce.

First, it’s important to consider the legal issues regarding parental consent for a child’s therapy.  If the parents share joint custody, the consent of only one is required; however, if the other parent objects at any point you will be required to end treatment.  It would be detrimental to the child to end therapy abruptly after a few weeks or months, and that is a risk inherent in beginning therapy without the consent of both parents.  At minimum, I would recommend asking the mother to provide a copy of the custody decree so you have confirmation of her report.

Although you might be legally permitted to begin therapy with only one parent’s consent, there are many clinical reasons to engage both parents in the therapy.  Your practice of meeting with both parents indicates you are aware of the importance of hearing both parents’ perspective on the child, the importance to the child of knowing that you maintain a relationship with both parents as he does, and the benefit to the child of providing consultation to both parents about their influence on him.  Part of the initial phase of any therapeutic relationship is establishing the frame, and making an exception to your usual practice would undermine the clarity of the frame and your role as a professional.

It is often helpful to reflect on some of the factors that may influence this mother to seek therapy for her son.  In addition to concern about his emotional wellbeing, she probably has other motivations, both conscious and unconscious.  She may wish to attribute any difficulty in her son’s emotions and behavior to his father in order to reduce her feelings of guilt and shame; she may be looking for an advocate in a legal proceeding regarding financial support or custody; or she may feel threatened by her son’s relationship with his father.  It is wise to assume that this mother’s request is more complex than it may initially appear and to remember that your role is to serve the child’s needs which overlap with but are not identical to those of his mother.

You may find it helpful to develop a standard way of describing your reasons for involving both parents in therapy, especially after divorce.  An example that would fit this case is “I understand your son’s dad has some reservations about therapy, but I have found it essential to talk with both parents in order to make sure I have the full picture.  I won’t be effective in helping your son if I’m not in touch with both of you.  How could we work that out?”.  It is possible that the mother will decide to look for another clinician, and you may feel pulled by your concern for the son.  However, maintaining a clear therapeutic frame is especially important in cases involving divorce.

Most clinicians find it challenging to work with families of divorce, so consultation with an experienced clinician will be helpful.  You may also find ongoing peer consultation to be a resource for navigating the emotionally charged issues that are part of this work.  If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Sources of Information for Assessment

I have had two therapy sessions with a 24-year-old woman who was hospitalized six months ago for suicidal ideation. She has been stable since then and wants to use therapy to understand what led to her suicidal thoughts. She has given me permission to talk with her psychiatrist and her parents with whom she lives, and she suggested I contact the hospital to get their report of her stay. I usually like to keep the therapy between me and the client, but in this case I think information from these other sources might help.

I agree that it might be necessary to expand beyond your client’s self report of history and symptoms in order to insure your client’s safety while she explores her past suicidal ideation. This question addresses the decisions inherent in conducting an initial assessment, which is discussed in Chapter 6 of my book. I’ll review whether and how to include information from other mental health providers, family members, and treatment records, after discussing the sources of information that come from your client sessions.

Therapy usually begins with a conversation between you and the client in which she tells you what difficulties are leading her to seek help. The initial phase of establishing a therapeutic alliance overlaps with doing an assessment of the client, so you develop a comprehensive picture of her life and circumstances that will guide your treatment approach. Your therapy sessions provide two sources of information about the client: her self-report and your observations. In the first two sessions, she has probably told you about her current concerns and symptoms, living circumstances, and relevant events from the past including her hospitalization. Whether you have been consciously aware of it or not, you are also observing her and noticing the nonverbal aspects of her presentation that are congruent or incongruent with her verbal presentation. Another aspect of the therapy sessions is the impact of the sessions on your own emotional state.

Client self-report and therapist observations are usually the primary source of assessment information, and sometimes are the only source. In this case, I would suggest expanding the client’s self-report by using one or more assessment measures. The Crpss-Cutting Symptoms Measure, contained in the Assessment section of the DSM- 5, is free and can be downloaded at https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures. Your agency may have other measures that are relevant to her presenting issues or you can find assessment tools at http://www.integration.samhsa.gov/clinical-practice/screening-tools. It may be useful to compare the client’s narrative report in session with her self report on an objective assessment measure. Your treatment approach will be different if her scores on objective measures indicate greater risk than she has reported to you in the first two sessions.

In terms of the other sources you mention, consulting with her psychiatrist seems essential so that you can develop a collaborative relationship as treatment providers. As your client explores the sources of her suicidal ideation, her symptoms may temporarily increase and her medication needs may change. The psychiatrist can also share the client’s treatment history and response, which you can compare with your client’s report. Talking with your client’s parents is more complicated and needs further evaluation. I recommend postponing that conversation until you know more about your client’s current relationship with her parents, past events in the family, and general family dynamics. Over time you will begin to make inferences about these issues as you hear more about her perspective on their interactions. I would begin this exploration by asking what she expects her parents would tell you and how she would feel about you hearing that from them.

Last, your client has suggested that you read the hospital record. This may contain useful historical and clinical information, so I would recommend requesting it. Be aware that it may be more difficult to obtain a hospital record than to talk with the psychiatrist, depending on the procedures in place there. The discharge summary is the most useful clinical document, so you can ask for that rather than for the full record which will include notes from each nursing shift during her stay that are less relevant to her current status.

Combining these sources of information will result in a comprehensive assessment, which is especially important in cases with elevated risk. Supplementing the therapy sessions with self-report measures, information from another provider, treatment records, and possibly family members will enable you to be clearer in your treatment approach. Your overall goal will be to respond to the client’s desire to understand her past suicidal ideation while helping her maintain physical and emotional safety.  If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Motivations for Becoming a Therapist

I just finished my first semester in a practicum placement, and I have begun to doubt my decision to become a therapist. I decided to enroll in graduate school because I liked to talk to people and heard from my friends that I was a good listener. Seeing clients this semester was much harder than I expected, and I didn’t feel like I was able to help them very much. How can I dnew2ecide whether to stay in the program or leave to pursue a different career?

The experiences that lead us to enter the field of counseling or psychotherapy are varied but often include ways we have taken a helping role in our personal relationships. The topic of our motivations to become a therapist, covered in Chapter 1 of my book, is complex because it includes emotions outside of our awareness as well as thoughts and feelings that we can identify directly. I’ll discuss some ways you can identify aspects of your motivation that may be influencing your doubts, then recommend how to approach your career decision.

Your enjoyment of conversations with your friends and feedback about your listening skills are common factors in leading someone to consider the psychotherapy field. An initial step in identifying more about your motivation is to reflect on what aspect of these conversations was most enjoyable to you. Did you like the process of getting to know someone more intimately, did you like to follow their stories, were you attracted to analyzing their problems or understanding their feelings? Getting more specific about the experiences that led you to this field will give you more information about your choice to enroll in a graduate program.

Next, it is important to look at aspects of your motivation that are less obvious and may not have entered your conscious awareness. Reflect on what you didn’t do or say in your social interactions or what you avoided by being a good listener. It’s possible that you are uncomfortable with the vulnerability that comes with sharing your own thoughts and feelings. You may have adopted a caretaking role because it was expected and/or rewarded in your family and culture or you may focus on others in order to avoid facing painful memories or being alone with your struggles.

Once you have looked more deeply at your motivation, examine the benefits that have come with your interpersonal style. Being a good listener may enable you to feel effective and empowered, and it may be a source of positive self-esteem as well as praise from others. If you help your friends and family members solve their problems, you can be less worried about your own difficulties. It is natural to assume that you will feel the same rewards with your clients, but clinical work is slower and more complex than personal interactions. It can be discouraging to face the difference between your expectations and the reality of working with clients whose problems involve psychological distress, sociocultural stressors, and mental health conditions. If you decide to stay on your path to becoming a therapist, you will need to adjust your expectations and find rewards in clinical work that are different than in your personal relationships.

Having engaged in self-reflection, I recommend that you reach out to others who can assist you in addressing your career question. Discouragement and doubt is often part of the learning process, and you are likely to feel understood and reassured by talking with professors and fellow students in your academic program and with supervisors and colleagues in your practicum setting. If you’re not already seeing a psychotherapist, this is a good time to begin personal therapy to learn more about the experiences that contributed to your career choice and to explore the meaning of your disappointment as a new therapist.

I hope you found this helpful in understanding more about your motivations for becoming a therapist. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Generational Differences in Therapy

stock-photo-27330798-senior-woman-and-psychiatristI have been working for the past year with a 78-year-old woman who has a moderate level of depression. She has a limited income, lives alone and has very little contact with other people. I have suggested several resources, including some that are online, that she could use to reduce her isolation. She agrees with me in session but doesn’t follow through. I’m starting to feel both frustrated and discouraged about being able to help her. I talked with my supervisor about ending the therapy but she told me to keep trying.

This question highlights the way in which generational differences can enter into therapy. When we work with individuals who are separated by one or two generations from us, we need to be aware of the age-related psychological issues facing our clients as well as the cultural differences that exist between us.

Starting with the psychological issues facing your client, she may be facing a high degree of loss and grief related to each of the risk factors you mention: limited income, living alone and lacking contact with others. Find out whether there were significant changes in your client’s life in the two to five years before she became depressed. If so, she may still be grieving the loss of income and financial status, the death of a spouse or close friends, and/or facing health problems that reduce her mobility. Even if these risk factors were present before she became depressed, she may have become less able to stretch her budget, participate in social activities or function independently as she ages. If you haven’t given her an opportunity to talk about feelings of loss or offered your empathy for her grief, I would suggest doing so. She will need to feel understood emotionally before she is ready to follow your suggestions about other resources that might help to improve her depression.

Another set of psychological issues arises in the fact that your relationship with your client mirrors a parent/child or grandparent/grandchild relationship for both of you. On your side, your frustration and discouragement probably include feelings you have about your parents or grandparents who faced or are facing some of the same issues as your client. Talk with your supervisor and therapist about these personal relationships to gain a better understanding of your countertransference. On your client’s side, working with a therapist who is young enough to be her child or grandchild exacerbates the sense of invisibility and devaluation she may feel as an older person in a culture that equates youth with worth. Your suggestions may feel condescending or invalidating if you are assuming you know more than she does about her experience and needs.

Moving to a cultural perspective, your client’s values and world view are different from yours due to the generational differences between you. Your client was a child during the Great Depression and World War II, came of age during a time of nationwide financial expansion, and experienced the civil rights, anti-Vietnam War and feminist movements as a young adult. Her experience of technology has spanned the period from radio and black-and-white television to internet and smart phones. It is a mistake to assume that she is comfortable, either emotionally or technologically, using online resources to reduce her social isolation. Her agreement with your suggestions may reflect a deferential attitude toward professionals who hold positions of authority, based in the values of her generation. Viewing your relationship as a cross-cultural one may help you to bridge your differences and approach your client with curiosity and interest.

I hope you find these suggestions helpful in working across generational differences in therapy. Please email me with comments, questions or suggestions for future blog topics.

Orientation to a New Training Site

new2I just started at my practicum or field placement site and I feel pretty overwhelmed.  What can I do to reduce my anxiety?

Starting at a new training site can be stressful, whether it’s your first placement or your fourth.  There are several things you can do to feel more confident and grounded.  As you read the suggestions below, you will probably find that some seem more relevant than others, based on your typical response to a new situation.

It is often helpful to review the requirements and procedures for your new site during the first week or two before you see your first client.  Some training agencies have a formal period of orientation and training and others are more informal.  Whatever the practice at your site, you will feel more prepared if you know 1) the treatment frame, i.e., where and when you will see clients, whether and how the client pays for sessions, how long sessions last and whether there is a limit on the number of sessions you will have; 2) the forms to be completed and signed by you and the client in the first session; and 3) agency procedures for clinical emergencies and back-up emergency supervision.  If this information isn’t provided in a formal orientation process, you can ask your supervisor or another more experienced colleague.

A second way to reduce anxiety is to think about ways to connect empathically with your assigned clients or the client population at your training site.  Often you will be working with clients who have survived serious trauma and are living with discrimination, prejudice, and poverty.  Instead of focusing on the client’s history and current circumstances, which can leave you feeling inadequate to make an impact, think about what your client may be feeling in coming to a session with you.  It is likely that she/he brings fear, shame and distrust to your first encounter as well as coping strategies that have enabled her/him to survive painful experiences.  Remember that your desire to understand your client is an essential and powerful first step in your relationship and will instill hope that you may have something helpful to offer.

Another very important aspect of managing the stress of starting in a new training site is to pay attention to your own physical, mental and emotional health.  You may be juggling school, job and family responsibilities in addition to your field placement limiting the time you have to take care of yourself.  In addition, many of us come into the behavioral health field with patterns of caretaking and self-neglect.  Working to balance our own needs with those of our clients is as much a part of the learning process as gaining clinical knowledge and skill.  You can start with something relatively simple like taking a 10-15 minute break to walk, stretch or do a mindfulness exercise during your day or bringing a healthy snack to work.  Supportive personal and professional relationships are also important, and personal psychotherapy is especially useful during clinical training.

I hope some of these suggestions help you in this overwhelming time.  Please email me with comments, questions or suggestions for future blog topics.